Ethical Dilemmas in Surgical Mission Trips During the COVID-19 Pandemic

This case is hypothetical and does not involve real patients or actual entities.

A long-running otolaryngology surgical teaching mission to Haiti was postponed in 2020 due to a combination of Haitian travel restrictions and American-based university travel bans during the coronavirus disease 2019 (COVID-19) pandemic. Several months have passed since the postponement of this recurring trip, and the local Haitian ear, nose, and throat (ENT) team has reached out to the international surgical teaching team to express their desire for surgical mission trips to return. The backlog of patients that the local team feels could not be treated without assistance continues to grow.

The COVID-19 vaccine is now available in the United States, and most US-based health care practitioners have been vaccinated, including all medical volunteers involved in this trip. University-based travel bans have also been lifted. Few Haitian health care providers have been vaccinated. Local Haitian travel restrictions are no longer being enforced, and it is legally possible to travel to the island. The international team has obtained enough personal protective equipment (PPE) to run a self-sufficient trip, but local PPE resources remain scarce.

Should the international surgical team restart mission work at this time? If so, what criteria need to be met for humanitarian organizations to provide safe and ethical care in the COVID-19 era when global inequality remains regarding vaccine distribution?

Cardiac surgery in low-income settings: 10 years of experience from two countries.

BACKGROUND:
Access to cardiac surgery is limited in low-income settings, and data on patient outcomes are scarce.

AIMS:
To assess characteristics, surgical procedures and outcomes in patients undergoing open-heart surgery in low-income settings.

METHODS:
This was a cohort study (2001-2011) in two low-income countries, Cambodia and Mozambique, where cardiac surgery had been promoted by visiting non-governmental organizations.

RESULTS:
In Cambodia and Mozambique, respectively, 1332 and 767 consecutive patients were included; 547 (41.16%) and 385 (50.20%) were men; median age at first surgery was 11 years (interquartile range [IQR] 4-14) and 11 years (IQR 3-18); rheumatic heart disease affected 490 (36.79%) and 268 (34.94%) patients; congenital heart disease (CHD) affected 834 (62.61%) and 390 (50.85%) patients, with increasingly more CHD patients over time (P<0.001); and the number of patients lost to follow-up reached 741 (55.63%) and 112 (14.6%) at 30 days. A total of 249 (32.46%) patients were lost to follow-up in Mozambique, remoteness being the only influencing factor (P<0.001). Among patients with known vital status, the early (<30 days) postoperative mortality rate was 6.10% (n=40) in Mozambique and 3.05% (n=18) in Cambodia. Overall, 109 (8.18%) patients in Cambodia and 94 (12.26%) patients in Mozambique underwent re-do surgery. In Mozambique, a further 50/518 (9.65%) patients died at a median of 23months (IQR 7-43); in Cambodia, a further 34/591 (5.75%) patients died at a median of 11.5months (IQR 6-54.5).

CONCLUSIONS:
Cardiac surgery is feasible in low-income countries with acceptable in-hospital mortality and proof of capacity building. Patient outcomes after cardiac surgery in low-income countries remain unknown, given the strikingly high numbers of lost to follow-u